I would like to give an additional gift to the SAEM Foundation. â¡ $1,000. â¡ $500. â¡ $250. â¡ $100. â¡ Other. $.
2019 MEMBERSHIP APPLICATION
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CONTACT INFORMATION Please type or print *Name
(Jonathan A. Smith, MD):
Preferred Name:
Former Name:
*Title: *Institution *Office
Name:
Address:
*City: *Primary
*State:
*Zip
Email:
*Office
Secondary Email:
Code:
Phone:
Mobile Phone:
Home Address: City:
State:
Academic Rank:
¨
Professor
¨ Assistant Professor
Graduation Date: Date of Birth:
Zip Code:
¨ Associate Professor
¨ Instructor ¨ Other: Preferred Contact Method: ¨ Mail ¨ Email Gender: ¨ Male ¨ Female
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MEMBERSHIP CATEGORY
¨ Faculty ¨ Young Physician Year 2 ¨ Young Physician Year 1
$665.00 $470.00 $275.00
¨ Fellow ¨ Resident ¨ Medical Student
$180.00 $180.00 $ 25.00
¨ Associate ¨ Military ¨ Emeritus
$305.00 $260.00 $100.00
ACADEMY SELECTION Please select your free academy or academies below
¨ Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) ¨ Academy of Emergency Ultrasound (AEUS) ¨ Academy of Geriatric Emergency Medicine (AGEM) ¨ Academy for Women in Academic Emergency Medicine (AWAEM)
¨ Clerkship Directors in Emergency Medicine (CDEM) ¨ Global Emergency Medicine Academy (GEMA) ¨ Simulation Academy
INTEREST GROUP SELECTION Please select your free interest group or groups below
¨ Academic Informatics Advanced Practice Provider Medical ¨ Directors ¨ Airway ¨ Climate Change and Health ¨ CPR/Ischemia/Reperfusion ¨ Critical Care Medicine ¨ Clinical Researchers United Exchange (CRUX) ¨ Disaster Medicine ¨ Educational Research ¨ Emergency Medical Services
¨ Emergency Medicine Transmissible ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨
Infectious Diseases and Epidemics (EMTIDE) Evidence-Based Health Care and Implementation Neurologic Emergency Medicine Observation Medicine Oncologic Emergencies Operations Palliative Medicine Pediatric Emergency Medicine Quality and Safety
¨ Research Directors Sex and Gender in Emergency Medicine ¨ (SGEM) Social Emergency Medicine and
¨ Population Health ¨ Sports Medicine ¨ Telehealth ¨ Toxicology ¨ Trauma ¨ Uniformed Services ¨ Wilderness Medicine
METHOD OF PAYMENT I would like to give an additional unrestricted gift to the SAEM Foundation of ¨ $1,000 ¨ $500 ¨ $250 ¨ $100 ¨ Other $
¨ Visa
¨ MasterCard
Name on Card: Card Number:
¨ Amex
¨ Discover
Checks should be made payable to SAEM Foundation
Expiration:
Signature: 1111 East Touhy Ave., Suite 540 | Des Plaines, IL 60018 Main: 847.813.9823 | Fax: 847.813.5450 |
[email protected]
PLEASE RETURN THE COMPLETED FORM VIA FAX OR EMAIL
Dues: Gift: Total: $ 0.00 CVV#:
